Provider Demographics
NPI:1124586599
Name:LUCILLE MANOR COMMUNITY RESIDENTIAL CARE, LLP
Entity Type:Organization
Organization Name:LUCILLE MANOR COMMUNITY RESIDENTIAL CARE, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:MACK
Authorized Official - Last Name:MINTZ
Authorized Official - Suffix:
Authorized Official - Credentials:CRCF
Authorized Official - Phone:803-546-0298
Mailing Address - Street 1:27 CARRIAGE OAKS CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-9300
Mailing Address - Country:US
Mailing Address - Phone:803-546-0298
Mailing Address - Fax:
Practice Address - Street 1:1004 R L COWARD RD
Practice Address - Street 2:
Practice Address - City:EASTOVER
Practice Address - State:SC
Practice Address - Zip Code:29044-9455
Practice Address - Country:US
Practice Address - Phone:803-546-0298
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness